Concussion

Introduction

Concussive head injuries have recieved recent media and medical attention, not only in the pediatric setting but also in professional contact sports such as football and boxing as well. The immediate and long term physical and neurophysicatric sequela are an active area of current research and interest.

Because of the increasing prevalance of competitive sports and the importance of early recognition of a concussive head injury, it is important for patients, parents, coaches and providers alike to be aware of the symptoms and initial steps in management.

Concussion Evaluation

The Sport Concussion Assessment Tool (SCAT2) offers a standardized method of evaluating athletes aged 10 years and older for concussion. It is a component of the 2008 Zurich Consensus Statement on Sport Concussion and is a screening evaluation tool designed for use only by qualified first responders or medical professionals.

The SCAT2 score does not independently determine the diagnosis of a concussion, nor does it independently determine the injured athlete’s recovery or return to play status. Such determination can only be made by a medical professional who has experience in the treatment of sport concussion

SCAT 2 is not a validated tool but is most commonly used and it combines many other evaluation tools such as:

Symptom checklist

Maddock’s questions of concentration and memory

Standardized Assessment of Concussion (SAC) sideline screening tool

Balanced Error Scoring System (BESS) for postural stability testing

Glasgow coma scale

SCAT2 is only designed for patients older than ten years

In younger children may need input from parents, coaches, teachers as well as patients to evaluate symptoms

Providers can use SCAT2/SAC if they are aware of the limitations in younger children and use their clinical judgment

Click on the logo below to access the SCAT2 tool

Post-Concussion Management

Children take up to 7-10 days to recover, which is significantly longer than adults

Never allow children to return to play on the day of the injury

Cognitive rest

​Activities that require concentration can exacerbate symptoms and may prolong recovery, patients may also perform poorly

Keep out of school or decrease school hours and homework

Avoid text messaging, video games, television, computers, reading

Physical rest:

If an activity worsens symptoms it should be avoided

Exercise, strenuous chores, and sexual activity should be limited

May be a role for light cardiovascular training as a form of treatment, but always below the level that induces symptoms, this is currently being investigated

Medications

NSAIDS can theoretically increase the risk of intracranial bleeds when used immediately after the injury, but no increased risk has been shown

Medications could include NSAIDS/acetaminophen/amitryptyline for headaches, SSRIs for depression or anxiety symptoms, zolpidem for insomnia, etc.

Patients should be symptom free without medications before they return to normal activities as medications can mask post-concussive symptoms

Other interventions:

Sunglasses for photophobia, earplugs and avoidance of headphones for phonophobia

May need to avoid driving due to slowed reaction times

Long Term Management

Long term sequela may not be readily visible after the injury, so reevaluation and a hightened sensitivity to depressive symptoms and continued academic issues particularly for repeated concussions is important months to years afterwards

High-Risk Management

Patients are high risk if they have:

More than 3 symptoms at presentation

Headache lasting >60 hours

Loss of consciousness for >60 seconds

Amnesia

History of prior concussion (concussions can occur with more minor impact, have more lasting effects)

Comorbid conditions

These high risk patients may need formal neuropsychiatric testing, and referral to a concussion expert

Return to Activies

Return to school

Slowly add back school activities, make sure that all teachers and administrators are aware of their deficits so they can monitor the child's performance and behavior as well

May need some short term adjustments such as decreased homework, extra time on tests, extra breaks, note takers, and forgiveness of makeup work, individualized education program (IEP) in more severe cases

Be aware that the most difficult subjects may be math, science, foreign languages

Standardized testing should be avoided until recovery is full so that they do not perform poorly

Return to Play Protocol

Only begin aftercomplete resolution of symptoms at rest, without medications

Return to play protocol: at least 24 hours for each step, if they develop symptoms stop the protocol and wait 24 hours before returning to the last asymptomatic step

Other groups make this diagnosis after as little as 1 week of prolonged cognitive, physical, or psychological difficulties

May consider prolonged time away from sports in some cases, including 3 concussions in one year or post-concussion syndrome for more than 3 months

When post-concussion syndrome is suspected, formal neuropsychiatric testing and referral to a neurologist is indicated to assist in management.

Second Impact Syndrome

If return to play while still symptomatic and sustain another injury, there is an increased risk of second impact syndrome

All cases reported in individuals under the age of 20

The proposed pathophysiology in this syndrome is cerebral vascular congestion leading to cerebral edema, increased ICP, coma, or even death

These patients should be managed by a neurologist familiar with concussive head injuries and highlights the importance of not playing while symptomatic.

Long Term Effects

The long term effects of concussions and repeated concussions include persistent problems with processing complex visual stimuli. Multiple concussions are associated with lower GPAs, confusion, amnesia, loss of consciousness, and future concussions.

There is currently research going on in this field in order to assess the severity of brain disease and the cummulative nature of injury.

Prevention and Legal Issues

Most states require school boards to develop concussion policies in order to minimize potential negative outcomes. These include steps such as:

Requiring parents and athletes to sign consent forms prior to dangerous play

Requiring specialized protective gear to be worn at all times.

Requiring adult supervision at all times, even during practice.

Requiring athlete removal from play if there is suspicion of concussion, and allowing return only after evaluation by a qualified health care professional

Education of student athletes, their parents and coaches in terms of the serious nature of head injuries, the importance of reporting injuries without punative recouse, and the symptoms to watch for in concussive injury.

Click on the logo below to access the "Heads Up" concussion prevention program sponsored by the Centers for Disease Control. The site contains useful information for providers, coaches, athletes and families in both English and Spanish.

Recently, there have been calls to limit the exposure to contact as well (click here for a recent news article) however this has been met by opposition including arguements that lack of practice in contact could in effect lead to more serious injury because athletes are not properly training in tackle procedures.